Physical Assessment Subjective Data (comments from client and/or significant others): “I have pain in my left leg” “My kids miss me a lot since I have been in the hospital” “I am a very religious person; I usually attend church every Sunday” Objective Data (findings from your physical assessment and pertinent diagnostic test results): Neuro : Orientation: A&O x 1, 2 or 3; Follows/doesn’t follow commands; MAE; PERRLA; blind, HOH, Spanish speaking only, etc; facial droop (if exists and which side). CV : RRR OR S1, S2 heard; no murmurs; edema present/absent; capillary refill brisk/slow OR >3/<3 seconds; skin turgor brisk/delayed (or you can put skin turgor under “skin”; pulses equal/unequal bilaterally (can also mention each specific pulse site ie., LT pedal pulse not palpable except by Doppler. Can put BP and pulse here if you would like (or if not on front page). Resp : lungs clear throughout/crackles in rt lung/LLL diminished; wheezes throughout; equal/unequal lung expansion; can also put O2 sat and RR rate here as well if not on front page
This is the end of the preview. Sign up
access the rest of the document.
This note was uploaded on 01/13/2011 for the course NURS 220 taught by Professor Zozuk during the Spring '08 term at Grossmont.